A 54-year-old female presents with a history of dysphagia affecting both food and liquids ...

A 54-year-old female presents with a 3 month history of dysphagia affecting both food and liquids from the start, along with symptoms of heartburn. What is the most likely underlying diagnosis?
A. Pharyngeal pouch
B. Gastric adenocarcinoma
C. Benign stricture
D. Oesophageal cancer
E. Achalasia

Answer:
E. Achalasia

Discussion: Dysphagia affecting both solids and liquids from the start - think achalasia. This is a classic history of achalasia with dysphagia affecting both solids and liquids from the start.

Achalasia 
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.

Clinical features 
 dysphagia of BOTH liquids and solids
 typically variation in severity of symptoms
 heartburn
 regurgitation of food - may lead to cough, aspiration pneumonia etc
 malignant change in small number of patients

Investigations 
 manometry: excessive LOS tone which doesn't relax on swallowing - considered most important diagnostic test
 barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance
 CXR: wide mediastinum, fluid level

Treatment
 intra-sphincteric injection of botulinum toxin
 Heller cardiomyotomy
 balloon dilation
 drug therapy has a role but is limited by side-effects